Biplane transesophageal echocardiographic diagnosis of cor triatriatum

Biplane transesophageal echocardiographic diagnosis of cor triatriatum. R Kacenelenbogen and P Decoodt Chest 1994;105;601-602 DOI 10.1378/chest.105.2.601 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/105/2/601

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1994by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

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selected Biplane Transesophageal Echocardiographic Diagnosis Cor

&Ss

?SWZ

of

Triatriatum*

Raymond

Kacenelenbogen,

M.D.

A transthoracic structure

left

the

chest

atrium

Decoodt,

Biplane

revealed plane

longitudinal

membrane

orifice

the

triatriatum.

for the

Doppler

or of

reported

tniatriatum all congenital cases, this

pulmonary cardiac

heart

venous

monary

venous

It may

transthoracic

Even

membrane and

Transesophageal

with

page

AoW \

the by

patients,

may be overlooked pulmonary

echocardiography

B

other of pul-

333

in symptomatic

atrial

left

signs

or anomaly

see

comments

of the of

with

be associated defect

echocardiography

of the

presence

in infants

septal

percent

majority

was

(atnial

drainage).

(0.1

the

In

obstruction.

editorial

malformation

made

of

pattern.

105: 601-02)

1994;

diseases).

diagnosis

malformations

For

cardiac

is a rare

The

assessment flow

(Chest

C

AO

with

transesophageal

useful

and

angiography.’

allows

a better

approach

LV

to the thagnosis.2 However, monoplane probes have limitations as they restrict the exploration to the transverse plane. The following case report illustrates the value ofthe longitudinal

view

in the

correct

evaluation

of a cor

tniatniatum.

\J#{231} ..

Liv I

CASE A 45-year-old mal

results

gram,

man

and exercise

vealed

a very

nor wall

ofthe

tnti

was

flow

atrial

stress

testing. thin

left atrium

ized,

separating

from

an anterior

position, wave and

near Doppler

#{176}Fromthe Brugmann,

The

tsOOHz

800Hz

1100Hz

He had nor-

attached

re-

to the ante-

pulsed-wave notch

valve.

Doppler and

mi-

an increased

and

with

posteroinferior level wave,

the four the

was wall

of this with

ofturbulent

In the (Fig

orifice

flow across

D#{233}partement de Brussels, Belgium.

pulmonary

ofthe

membrane

Cardiologie,

Doppler

identified

the

was

a low

‘tj r)

I ?44

ie 1

I

citron

.(t

!

ilcy

k. \.._

\/ I

4

.siE*-i

ie*Eie-T

S

VOLUst

.txt

pulsed-

systolic

wave

of 1.2 mIs. There membrane

:::

1

how-

in an eccentric The

.

did not

plane,

1, bottom). velocity

veins

appendage

longitudinal

revealed

a maximal

probe.

was visual-

left atrial

the color-coded

in diameter

performed

biplane

the left atrium

receiving

jet in this plane.

at the pattern

across

was

a 5-Mhz

No fenestration

1, center),

of 1.8 cm the

and

in connection

mitral (Fig

870)

chamber

chamber

a tall end-diastolic

was no mosaic

COOHz

electrocardio-

examination

SSD

a membrane

a posterior

a normal

an orifice

pain.

echocardiography

structure

1, top).

(Aloka

plane,

any abnormal

ever,

chest radiograph,

Transthoracic linear

echocardiographic

in this plane

reveal

chest

by a middiastolic

unit

In the transverse

seen

/OOH

wave.

an ultrasound

and with

(Fig

characterized

contraction

atypical

examination,

A transesophageal using

with

inconspicuous

100)4:

RiPi

REPORT

presented

of physical

V

a linear

presenting

a cor

most

was

:%:#i

M.D.

disclosed of an adult

pain.

echocardiography the

Pierre

echocardiogram

in

atypical

and

;

by color

H#{244}pital Universitaire

FIGURE 1. lop (A). lransthoracic para.sternal long axis view. A thin linear structure attached to the antenor xtrial wall is barely isible (arrow). This stnicture was niore ol)vlons on real-titia.’ inlagnig (tIl(l when playing the recor(le(l videotape. Center ( B ). Transesopliageal transverse view: the membrane diiding tle left atrium (arrow) seems unperforated in this plane. Bottom (C). Transesophageal longltll(linal iew: the diameter of the orifice (arrow) can be evaltlate(l to 1 il cm.

CHEST

I 105

I

2

Downloaded from chestjournal.chestpubs.org by guest on July 13, 2011 © 1994 American College of Chest Physicians

I FEBRUARY,

1994

601

Doppler.

The

notched

atrial

Given

through

the

mitral

flow

exhibited

contraction

clinical

perfect

alow

rapid

filling

wave,

and

a tall,

color

wave.

the membrane,

flow

HeartJ

tolerance

and the absence

no treatment

of gradient

Doppler

1991;

5 Hoffmann

was advised.

R,

triatriatuni:

traction wave.

This observation tween incomplete

illustrates the concept of a continuum incorporation of the main pulmonary

and

ofcor

of the

pact thoracic

were

triatniatum.6

plane

longitudinal

and

the

It demonstrates

in a situation

transesophageal

the

where

transverse

plane

bevein

the trans-

REFERENCES

diagnosis

Cardiol

1982;

7 Mon

2 Goldfarb

right

left

J,

atrial

Am Soc 3 SchlOter

1989;

magnetic

diagnosis

1983;

2:1011-15

4 Ludomirsky

WG,

mitral

Kronzon

the

role

resonance

BA, Thier

P. Transesophageal

in the

K, Dohi

ring.

AmJ

John Lindow,

ofcor

I. A patient

A, Erikson

W, Schmiegel

two-dimensional

triatriatum C, Yick

Hanrath

diagnosis

P. of

EurHeartJ

critically

Four

resulted

cor 1992;

in the GW,

adult.

Cooley

WH, Coil

Br Heart

J

common

clarification

1992;

blood

by

86:4-5

in

flowpaftems

117:1167-68

ill

findings

included

and can

occur

In

measurement

of

gradual

and

Ill

often

of free

be

patients

phenytoin

of

phenytom with

detected

only

by

levels.

(Cheat

I

drug. in level

Marked

critically

drugs

unbound

decrease

signs.

can

toxicity.

displacing

fraction

cerebeflar

hypoalbuminemia

phenytoin

concomitant

increased

consciousness

direct

developed

patients

an

toxicity

M.D.

1994;

105:

602-04)

critical care units, generalized tonic-clonic seizures occur most often in patients with acute electrolyte abnormalities, in patients with drug toxicity, or in patients undergoing sudden narcotic drug withdrawal.’ Phenytoin is the first-line drug in treatment of seizures. Monitoring of total serum ‘

however,

may be misleading

further

In addition,

increase

free

because

serum that drugs

phenytoin

the high

pro-

albumin maybe are associated

reduced with antibiotics) may

(often

concentration

by competitive

displacement from protein-binding sites. Unfamiliarity with this pharmacologic interaction in a critical care setting may prompt an increase in the dose ofphenytoin in a patient with a normal total serum phenytoin level who in fact has an elevated free phenytoin level. We report the cases offour patients with severe

phenytoin

intoxication

as a result

CASE CASE

of hypoalbuminemia.

REPORTS

1 woman

was

foraperforated by sepsis.

After

A computed

intravenous

EEG

(ionized

diazepam became

and

(CT)

received

increased.

At that epileptiform

was

and

She

She was

had

treated

ofl,400

mgof

the maintenance

the EEC activity.

of

status

normal.

aloadingdose

was

her level

nonconvulsive

scan

time,

foilowing course

seizure,

2.7 mg/dl).

unresponsive,

no specific

ICU

postoperative

showed

calcium,

gradually

was but

An

The

tonic-clonic

tomographic

hypocalcemia

to the surgical

ulcer.

a single

deteriorated.

phenytoin. She dose ofphenytoin eralized slowing

admitted

duodenal

showed On

gen-

postopera-

Krebber

echocardiography

J Am

J

of the

mass:

pulmonaiyvein 1989;

or in

Clinical

with

with

in diagnosis.

and

Remnant atrial

R.Ph.; and Eelco F. M. WIjdlcks,

Hypoalbuminemla

epilepticus.

of transesophageal imaging

T. Mitral

Am HeartJ

consciousness

pitfalls

2:350-53

M, Langenstein

HJ, Kolmar

and supravalve

membranes:

and

Echo

Daniel

Am

Phenytoin Toxicity Associated With Hypoalbuminemia in Critically Ill Patients*

profound

A, Weinreb

and

membrane:

49:780-86

echocardiography

602

triatriatum

atrial

M.

for a left

echocardiography.

cortriatriatum.

complicated

S. Concealedleft

ofcor

the

Doppler.

C, Riley

mistaken

transesophageal

surgery

in the

vein

An 80-year-old

M, Hirshfeld

FA,

in

ofcolour

W, Wakmonski

pulmonary

hypoalbuminemia.

approaches

disease.

1 Jacobstein

Flachskampf

pensityofphenytoin bindingto in critical disease states

even with the aid ofthe color-coded Doppler. Interestingly, the final result on the clinical decision in this patient was not significantly altered. In the absence of any clinical abnormalities, while the biplane transesophageal echocardiogram adds improved diagnostic capability its additional clinical value is sometimes controversial. Given the rarity ofcor tnatriatum, this observation is limited to a single case report. However, it emphasizes the role of biplane transesophageal echocardiographyas the appropriate diagnostic technique in patients suspected of having this particular conheart

H,

echocardiography incrementalvalue

6 Manning

phenytoin,

im-

unsatisfactory,

genital

in an adult.

13:418-20

A thorough anatomic assessment is mandatory in cor triatriatum. The openingofthe diaphragm mayhave manyconfigurations. It may be multiple or absent. Associated anomalies must be ruledout. The differential diagnosis has to be made with asupramitral membrane (a shelf-like membranejust above the annulus), a dilated coronary venous sinus (in cases of a persistent left superior vena cava), exuberant atrial septum aneurysms, or nonpathologic remnants of the common pulmonag), vein.6 Transesophageal echography with color Doppler appears well suited to achieve these goals. The patient had no venous congestion, as expected from the diameter of the visible orifice. However, the presence of this large orifice escaped the transverse plane, probably because of its inferior location, where the access is more difficult (the probe may lose contact with the esophageal wall at this level). This is not the case in the longitudinal plane, where the orifice was readily identifiable. The flow pattern through the orifice was similar to other cases with more severe obstruction.7 Most ofthe flow occurs during the ventricular diastole, because less blood is aspirated from the pulmonary veins by the abnormal left atrium during its relaxation. The leftventricular inflow pattern is also consistent with this phenomenon. It usually shows an additional middiastolicwave or, in case ofslight tachycardia, as in our patient, an increased end-diastolic wave resulting from a delayed rapid filling wave superimposed on the atrial con-

syndrome

triatriatum

of car

Lambertz

Transesophageal

DISCUSSION

the

evaluation

120:451-52

Cardiol

D. Transesophageal

From the Departments of Neumlo (Dr. Wijdicks) and Services (Mr.Lindow), Saint Maiys}Iospital, Mayo Clinic Foundation, Rochester, Minn. Rts&sti: Dr Wijdicks, Neurology W84, Mayo Clink.

Phenytoin

Toxicfty

and

Hypoalbuminemia

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(Lindow,

Pharmacy and Mayo

Rochester,

VvlJd!cks)

Biplane transesophageal echocardiographic diagnosis of cor triatriatum. R Kacenelenbogen and P Decoodt Chest 1994;105; 601-602 DOI 10.1378/chest.105.2.601 This information is current as of July 13, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/105/2/601 Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.

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